OSJCT Gregory House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The service demonstrated an exceptionally strong and embedded learning culture, where continuous improvement directly enhanced safety and outcomes for people. The registered manager provided inspirational and highly effective leadership, ensuring all incidents and accidents were rigorously reviewed and used as opportunities to drive meaningful change. Analysis of trends, particularly in relation to falls, led to small but impactful improvements in day-to-day practice, resulting in a sustained and measurable reduction in falls. This meant people experienced safer care while being supported to maintain and improve their mobility in a way that was tailored to their individual needs.

There was a comprehensive and well-coordinated approach to risk management, supported by robust, person-centred assessments and clearly defined action plans. Monthly multidisciplinary meetings ensured risks were consistently identified, monitored, and addressed promptly, enabling swift interventions that reduced the likelihood of harm and improved people’s experiences.

The service fostered a mature and transparent culture of reflection, where learning was shared openly and effectively through real-time discussions, structured handovers, and well-led team meetings. In addition, whole-service reflective reviews were held monthly, providing a safe and inclusive space to critically analyse incidents such as falls, pressure damage, medication errors, injuries, and deaths. These reviews were clearly focused on improving outcomes for people through shared learning and preventative action.

As a result, the service demonstrated a highly proactive and responsive approach to learning, where insight and reflection consistently led to tangible improvements. This ensured people experienced safer, more responsive care within a service that was committed to continually evolving and achieving the best possible outcomes.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had effective systems and processes in place to support safe care and treatment through coordinated care pathways. The service worked collaboratively with a range of healthcare professionals, including GPs, district nurses, specialist nurses and hospital teams, to ensure people received safe, consistent and joined-up care.

Records demonstrated clear timelines of engagement with external professionals, evidencing continuity of care and effective information sharing. Systems were in place to ensure that changes in people’s health were identified promptly. Staff recognised signs of deterioration and escalated concerns in a timely way, working in partnership with relatives and relevant professionals.

This approach ensured appropriate action was taken without delay, reducing risks to people’s health and supporting safe outcomes.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People consistently told us they felt safe living at the service. One person said, “Of course it’s safe here – I’ve no worries at all. We’re looked after so well.” A relative who visited every day shared that staff made people feel, “Like they were a family,” adding, “It’s more than safe here.”

People’s confidence in their safety was supported by the provider’s robust policies and protocols for identifying and reporting abuse. Staff received regular safeguarding training and demonstrated strong awareness of how to recognise and respond to concerns. People were assured that if they ever raised a worry, staff would take prompt action to keep them safe.

Staff told us they felt confident in recognising and responding to safeguarding concerns. They described how their regular training had strengthened their understanding of the different types of abuse people could be exposed to, and how this informed their everyday practice. Staff were clear about the actions they would take if they witnessed or were told about any concerns. They also expressed confidence in the registered manager and management team, telling us they trusted them to act promptly on any issues raised.

The registered manager followed the principles of the Mental Capacity Act 2005 (MCA) when depriving people of their liberty. People can only be deprived of their liberty where this is in their best interests and legally authorised under the MCA, typically through the Deprivation of Liberty Safeguards (DoLS) in care home settings.

We saw evidence that appropriate authorisations were in place for people who required them, and that MCA principles were consistently upheld.

The provider always worked well with people to fully understand and manage risks by thinking holistically. Staff provided care that fully met people’s needs and was safe, supportive and enabled people to do the things that mattered to them.

People’s care plans were comprehensive, current and exceptionally detailed, providing staff with clear, personalised guidance on how to support each person safely. These included robust risk assessments relating to skin integrity, nutrition and falls, with staff demonstrating an exceptional understanding of individual needs and confidently describing the tailored strategies used to keep people safe, reflecting knowledge that exceeded routine expectations. The registered manager further strengthened risk management through active oversight, including closely monitoring people’s weights and responding promptly to any concerns through timely referrals to GPs and dieticians, ensuring early intervention and reducing the risk of deterioration.

This strong approach enabled positive risk-taking, with independence consistently promoted in a safe and controlled way. Staff supported people to remain as independent as possible while effectively managing risks, with one person explaining, “I can push my wheelchair around, get into a chair by myself and go where I want. I wash and dress myself too.” A relative described how staff had worked proactively following a fall to implement tailored strategies that rebuilt mobility while minimising future risk. This demonstrated a highly embedded culture of proactive, person-centred risk management, where people were supported to maintain control and independence while remaining protected from harm.

The registered manager had innovatively introduced a nationally recognised, structured framework aligned to the Hudson Safety Culture Ladder to continually strengthen and evolve the service’s safety culture. This enabled the service to move beyond a reactive approach, with leaders and staff increasingly anticipating, identifying and mitigating risks early, demonstrating a mature, proactive approach to risk management and consistent safeguarding of people.

Staff at all levels had fully embedded in this approach and demonstrated a strong sense of ownership, accountability, and collective responsibility for maintaining safety. This proactive culture translated directly into improved outcomes for people, with risks identified earlier, managed more effectively, and mitigated before harm could occur.

As a result, people experienced consistently safe, proactive, and high-quality care, underpinned by a strong culture of prevention and continuous learning. Staff were confident, empowered, and committed to delivering the highest standards of care.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment in which people lived was well maintained and presented in a good decorative condition. The registered manager provided evidence that regular servicing of the premises and equipment was carried out. The maintenance team addressed any required repairs promptly and effectively.

There was an ongoing programme of refurbishment, improvements to the dining and communal areas. We saw evidence that people living at the service had been actively involved in planning these enhancements.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by adequate numbers appropriately trained staff. Our review of staff rosters showed the registered manager and their team worked to maintain staffing levels in line with the service’s established requirements. A dependency tool was used to calculate safe staffing levels, and the registered manager told us these were reviewed regularly. They and the deputy manager also spent significant time on the floor observing practice and monitoring people’s care to ensure staffing levels remained safe.

The registered manager followed safe recruitment practices. There was a clear recruitment policy, which staff followed.

Staff did not start work until references were checked and satisfactory Disclosure and Barring Service (DBS) checks were completed. This helped make sure staff were suitable for their roles.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Throughout our assessment, we found the service to be clean and well maintained. People told us they were satisfied with the cleanliness of the environment. Staff followed safe infection prevention and control practices in their day‑to‑day work, and we observed staff wearing appropriate personal protective equipment (PPE) when required. Staff demonstrated good understanding of how to reduce the risk of infection, and regular, monitored cleaning schedules were in place to support staff in maintaining high standards of cleanliness.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely from staff who were trained in medicines administration. People told us they received their medicines on time, and staff responded promptly to any reports of pain or discomfort.

People were actively supported to manage their own medicines wherever possible, promoting independence and choice. Individual risk assessments and regular monitoring ensured this was done safely and in line with each person’s needs and preferences.

Where medicines were administered covertly, this was done in line with best practice, with decisions made in the person’s best interests and involving family members and relevant healthcare professionals.

There were systems in place to monitor medicines safety. For example, detailed analysis of medication errors led to a measurable reduction in incidents, ensuring people received safer care. Proactive systems meant that potential errors were identified and addressed at an early stage, often before they could impact people, significantly reducing risk and promoting reliable, safe medicines management.